Mosby CHP 24

CHAPTER
24
Skin Care
and
Prevention
of Wounds
OBJECTIVES
After reading this chapter, the learner should be able to do the following:
• List clients at risk for skin tears and pressure ulcers.

• Describe the causes of skin tears and how to prevent them.
• Describe the signs, symptoms, and causes of pressure ulcers and ways to prevent
them.
• Identify the pressure points in the basic bed positions and sitting positions.
• Describe the causes of leg and foot ulcers and ways to prevent them.
• Describe the process, types, and complications of wound healing.
• Describe what to observe about wounds and wound drainage.
• Explain how to secure dressings.
• Explain the guidelines for applying dressings.
• Describe how to meet the basic needs of clients who have wounds.
• Apply in your practice the procedures described in this chapter.
460 http://evolve.elsevier.com/Canada/Sorrentino/SupportWorker
KEY TERMS
abrasion A partial-thickness wound caused by the incision An open wound with clean, straight edges;
scraping away or rubbing of skin. p. 463 usually intentionally created with a sharp
arterial ulcer An open wound on the lower legs instrument. p. 463
and feet caused by poor arterial blood flow. p. 475 infected wound A wound containing a large
bedsore See pressure ulcer. p. 465 amount of bacteria and showing signs of infection.
bony prominence An area on the body where the Also known as dirty wound. p. 463
underlying bone seems to “stick out.” p. 465 intentional wound A wound created for
Braden Scale A scale used to predict the treatment. p. 463
likelihood of a client developing a pressure laceration An open wound with torn tissue and
ulcer. p. 467 jagged edges. p. 463
bruise See contusion. p. 463 necrotic tissue Localized tissue death as a result
chronic wound A wound that does not heal of disease or injury. p. 482
easily in a timely manner. p. 463 open wound A wound in which skin or the mucous
circulatory ulcer An open wound on the lower membrane is broken. p. 463
legs and feet caused by decreased blood flow partial-thickness wound A wound in
through arteries or veins. Also known as vascular which the dermis and epidermis of skin are
ulcer. p. 473 broken. p. 463
clean-contaminated wound A wound occurring penetrating wound An open wound in
from the surgical portal of entry into the urinary, which skin and underlying tissues are
reproductive, or digestive system. p. 463 pierced. p. 463
clean wound A wound that is not infected; peri-wash A type of gentle soap for skin.
microbes have not entered the wound. p. 463 It is used primarily as a cleanser and
closed wound A wound in which tissues are deodorizer of the perineal area soiled by
injured but skin is not broken. p. 463 urine and feces. p. 480
contaminated wound A wound with a high picture-frame dressing A type of dressing in
risk for infection; microbes have entered the which tape is applied to all four edges to reduce
wound. p. 463 the likelihood of the dressing wrinkling or falling
contusion A closed wound caused by a blow to off. p. 484
the body. Also known as a bruise. p. 463 pitting edema A type of edema that is evident by
decubitus ulcer See pressure ulcer. p. 465 an impression left in the skin upon compressing
dehiscence The separation of wound layers along the fingers into the swollen tissues and then
a surgical suture line. p. 476 removing the fingers. p. 473
dirty wound See infected wound. p. 463 pressure points Bony prominences that bear the
edema Swelling in tissues caused by an weight of the body in certain positions and may
accumulation of fluid. p. 473 lead to pressure ulcers. p. 465
evisceration Separation of the wound pressure sore See pressure ulcer. p. 465
accompanied by protrusion of abdominal pressure ulcer Any injury caused by unrelieved
organs. p. 476 pressure. Also known as decubitus ulcer,
friction Resistance that skin encounters when it bedsore, or pressure sore. p. 465
rubs against another surface such as clothing, puncture wound An open wound made by a sharp
bedding, or another fold of skin. p. 463 object; entry into skin and underlying tissues may
full-thickness wound A wound in which the be intentional or unintentional. p. 463
dermis, epidermis, and subcutaneous tissue purulent drainage Thick drainage from a wound or
are penetrated; muscle and bone may be body orifice, which may have a foul odour;
involved. p. 463 purulent drainage is yellow, green, or brown and
gangrene A condition in which tissue dies and then may indicate an infection. p. 478
decays. p. 473 sanguineous drainage Bloody drainage. p. 478
hematoma The collection of blood under skin and serosanguineous drainage Thin, watery drainage
tissues. p. 476 that is blood-tinged (sanguineous). p. 478
hemorrhage The excessive loss of blood within a serous drainage Drainage that is clear and watery
short period. p. 476 fluid. p. 478
461
shearing Tearing of skin tissue caused when the trauma An accident or violent act that injures skin,
skin sticks to a surface (usually the bed or chair) mucous membranes, bones, or internal organs
and deeper tissues move downward, exerting (physical trauma) or causes an emotionally painful,
pressure on the skin. p. 464 distressful, or shocking result (emotional trauma),
shock The condition that results when there which often leads to lasting mental and physical
is not enough blood supply to organs and effects (psychological trauma). p. 462
tissues. p. 476 unintentional wound A wound resulting from
skin tear A break or rip in skin; the epidermis trauma. p. 463
separates from the underlying tissue. p. 463 vascular ulcer See circulatory ulcer. p. 473
stasis ulcer See venous ulcer. p. 473 venous ulcer Open wounds on the lower legs and
Steri-Strip A proprietary type of adhesive bandage; feet caused by poor blood return through the
thin strips are applied across a skin tear to bring veins. Also known as stasis ulcer. p. 473
the skin edges together and hold them together wound A break in the skin or mucous
while the wound heals. p. 464 membrane. p. 462
Skin is the body’s first line of defence. It protects the BOX 24–1 Common Causes of Skin
body from microbes that cause infection and disease.
As a support worker, you have to consider providing
Breakdown
good skin care to your clients one of your most
important tasks. Infants, older adults, and clients
• Age-related changes in the skin
who have disabilities are at greatest risk for skin
• Skin dryness
breakdown because their skin can be easily injured
• Fragile and weak capillaries
due to limited mobility and certain health conditions
• General thinning of the skin
that make their skin more susceptible to injury. It
• Loss of fatty layer under the skin
should be noted that the skin of infants and the skin
• Decreased sensation to touch, heat, and cold
of older adults are quite different from one another.
• Decreased mobility
Support workers should also be aware that clients
• Sitting in a chair or lying in bed most or all of
the day
who are diabetic or have circulation challenges (see
Chapter 37) are prone to delayed healing times and
• Persistent diseases (e.g., diabetes, high blood
pressure)
wound and skin infections. Support workers should
look for signs of skin problems and report them
• Diseases that decrease circulation
immediately to either the nurse or their supervisor,
• Poor nutrition
depending on their workplace. BOX 24–1 lists the
• Poor hydration
common causes of skin breakdown.
• Incontinence
A wound is a break in the skin or the mucous
• Moisture in the dark areas of the body (skin
folds, under breasts, between toes, and perineal
membrane, which becomes a portal of entry for areas)
microbes. Wounds have many causes. A surgical inci-
sion leaves a wound, for example, and wounds often
• Pressure on bony parts (see FIGURE 24–1 on
page 466)
result from trauma—an accident (such as a fall or
vehicular accident) or violent act (such as a gunshot
• Poor care of fingernails or toenails
or stabbing) that injures skin, mucous membranes,
• Friction and shearing
bones, or internal organs. Other wounds may result
from immobility or poor blood circulation. how to promote wound healing. You must prevent
The support worker’s role in wound care depends skin injury and give good skin care. When injury does
on provincial or territorial laws, job description, and occur, infection is a major threat, so wound care is
the client’s condition. Whatever your role, you need important for preventing infection and further injury
to know the types of wounds, how wounds heal, and to the wound and nearby tissues.
462
CHAPTER 24 Skin Care and Prevention of Wounds 463
BOX 24–2 Types of Wounds

Intentional Wound and Unintentional Wound the risk for infection is greater than with a clean
• Intentional wound—created for treatment; for wound
example, surgical incisions, as well as sterile veni- • Contaminated wound—unintentional wound
punctures (vein punctures) for starting intra- (such as from a stabbing) that is not created
venous (IV) therapy or for collecting blood under sterile conditions and is generally contam-
specimens inated and has a high risk for infection; wound
• Unintentional wound—results from trauma— contamination can also occur from a break
for example, falls, vehicle accidents, gunshots, in surgical asepsis and from the spillage of
stabbings intestinal contents; tissues may show signs of
inflammation
Open Wound and Closed Wound • Infected wound (dirty wound)—wound con-
• Open wound—a break in the skin or mucous taining a large amount of bacteria and showing
membrane; intentional and most unintentional signs of infection; for example, old wounds, sur-
wounds are open gical incisions into infected areas (such as a rup-
• Closed wound—injury to tissues without break- tured appendix), and traumatic injuries that
ing the skin; for example, bruises, twists, and rupture the bowel
sprains • Chronic wound—one that does not heal easily
in a timely manner, such as a pressure ulcer or
Clean Wound and Contaminated Wound
circulatory ulcer (see pp. 465–475); any wound
• Clean wound—not infected, meaning microbes that is continually exposed to friction, pressure,
have not entered the wound; closed wounds and or moisture can become chronic
intentional wounds created under surgically
aseptic conditions are usually clean; because the Partial- and Full-Thickness Wounds (Described
urinary, respiratory, and digestive systems are not by Wound Depth)
entered, there is a reduced risk of infection • Partial-thickness wound—the dermis and epi-
• Clean-contaminated wound—result of the sur- dermis of the skin are broken
gical entry (sterile technique used) of the urinary, • Full-thickness wound—the dermis, epidermis,
reproductive, or digestive system; because these and subcutaneous tissue are penetrated; muscle
systems are not sterile and contain normal flora, and bone may be involved
• Penetrating wound—an open wound in which

TYPES OF WOUNDS skin and underlying tissues are pierced
Wounds are described in many ways (BOX 24–2), • Puncture wound—an open wound made by a
including the following: sharp object; entry into skin and underlying tissues
may be intentional or unintentional
• Abrasion—a partial-thickness wound caused by
the scraping away or rubbing of skin
• Contusion—a closed wound caused by a blow to SKIN TEARS
the body (a bruise) A skin tear is a break or rip in the skin. The epider-
• Incision—an open wound with clean, straight mis (top skin layer) separates from the underlying
edges; usually intentionally created with a sharp tissue. The hands, arms, and lower legs are common
instrument sites for skin tears. Many older adults have very thin
• Laceration—an open wound with torn tissues and fragile skin, and even slight pressure or friction
and jagged edges can cause a skin tear. Friction is the resistance that
464 CHAPTER 24 Skin Care and Prevention of Wounds
skin encounters when it rubs against another surface • Bumping a hand, arm, or leg on any hard surface
such as clothing, bedding, or another fold of skin. such as a bed, bed rail, chair, wheelchair footrest,
Clients who are most likely to have skin tears are or table
those with very dry and paper-thin skin. • Holding on to a client’s arm or leg too tightly
• Repositioning, moving, or transferring a client
without a transfer sheet or other nonfriction
Causes of Skin Tears surface, the absence of which can cause the client’s
Skin tears occur due to friction, shearing, pulling, skin to rub against the surface and even tear
or direct pressure on skin. Shearing is the • Bathing, dressing, and other tasks
tearing of skin tissues as a result of skin sticking • Pulling buttons or zippers across fragile skin
to a surface (usually the bed or chair) and deeper
tissues moving downward, exerting pressure on the It is always your responsibility to be careful when
skin (see Chapter 25). Blood vessels and tissues moving, repositioning, or transferring clients. Skin
become damaged, reducing blood flow to the area tears are painful, and they can become portals of
and increasing the risk for a pressure ulcer. Shear- entry for pathogens. Tell your supervisor at once if
ing occurs when the client slides down in the bed you cause or find a skin tear, bruise, bump, or scrape
or chair. Skin tears are commonly caused by the (see the Supporting Mrs. Nippeskaya: Preventing
following: Further Skin Injuries in a Frail Client box).
forearm around her elbow. She also had several

Supporting Mrs. Nippeskaya: bruises and scrapes on her right arm and had dif-
Preventing Further Skin ficulty moving her leg. Mrs. Nippeskaya was taken
Injuries in a Frail Client by ambulance to the local hospital, where she was
examined, her leg was X-rayed, and her skin tears
You are the support worker assigned to care for were covered with Steri-Strip bandages (which
Mrs. Nippeskaya, 56, a widow with ovarian cancer hold the skin edges together during healing). Back
currently living at the long-term care facility where at the facility, she agreed to be lifted with a mech-
you are employed. Her daughter is trying to make anical lift (see Chapter 25) for toileting.
arrangements to move her mother to the town Today, you and your co-worker apply the mech-
where she lives. Because of Mrs. Nippeskaya’s illness anical lift sling carefully and properly under Mrs.
and her treatments, she has lost approximately Nippeskaya’s hips, according to your agency’s
50 kg (110 pounds) over the past year. policy. However, while raising her up, you notice
Mrs. Nippeskaya has been very weak and dizzy that there is blood on her pants over her buttock
for several months now, and while at home, she was area. You carefully lower her and remove her pants
frequently falling or bumping into the corner of to find the source of the blood.
her bed or dresser. Since being admitted to your You discover that her buttock skin tear has
facility, she has been advised to ask for assistance reopened due to the friction of the mechanical lift
to go to the washroom. Yesterday, however, she did sling on her skin. While your co-worker stays with
not ask for assistance, and when she stood up on Mrs. Nippeskaya, you summon assistance from the
her own, she lost her balance and fell to the floor, nurse. You are instructed to document everything
hitting the side of her bed. you have observed and to switch to another mech-
The nursing staff heard Mrs. Nippeskaya fall and anical device that does not require placing a sling
came to her side immediately. Upon examination, around the client’s buttocks. The nurse then applies
they observed a 3.75-cm (1.5-in.) tear on her right clean Steri-Strips to Mrs. Nippeskaya’s skin tear
buttock and a 2.5-cm (1-in.) tear on her right and fills out an incident report (see Chapter 22).
Clients at Risk for Skin Tears BOX 24–3 Guidelines for Preventing
Clients at risk for skin tears include the following: Skin Tears
• Follow the care plan for moving, lifting, repos-
• Those who require moderate to complete help in itioning, transferring, dressing, and bathing the
moving client.
• Those who have poor nutrition or are very thin
• Keep the skin moisturized, as per the care plan.
• Those who are poorly hydrated
• Offer fluids, as per the care plan.
• Those with altered mental awareness; for example,
• Dress and undress the client carefully.
clients with dementia may resist care and move
quickly and without warning, which can cause
• Dress the client in soft clothing with long
sleeves and long pants. Allow the client to make
skin tears choices.
• Those who are older
• Keep your fingernails short and filed smooth.
• Keep the client’s fingernails short and filed
Prevention and Treatment of Skin Tears smooth. Report to your supervisor if the client’s
toenails are long and rough.
Giving careful and safe care helps prevent skin tears
and further injury. Follow the guidelines in BOX 24–3.
• Do not wear rings with large or raised stones or
edges that could snag on anything.
The physician and the nurse direct skin care
treatment and may order dressings. Elastic wraps
• Follow safety guidelines when transferring or
lifting the client to and from a bed or wheel-
protect the skin from injury and help the healing chair (see Chapter 25).
process. Follow the care plan and your supervisor’s
instructions.
• Prevent friction and shearing during lifting,
moving, transferring, and repositioning.
• Use a turning sheet to move and turn the client
PRESSURE ULCERS in bed.
A pressure ulcer (also called a decubitus ulcer,
• Use pillows to support arms and legs, as per the
care plan.
bedsore, or pressure sore) is any injury caused by
unrelieved pressure. It usually occurs over a bony
• Be patient and calm when the client is confused
or agitated or resists care.
prominence—an area where the bone seems to “stick
out” and is compressed under the client or between
• Ensure that bed rails and wheelchair arms, foot-
rests, and leg supports are padded. Follow the
the client’s skin folds. The shoulder blades, elbows, care plan.
hip bones, sacrum (the bone in the lower part of the
spine), knees, ankle bones, heels, and toes are all
• Ensure that body parts are not pressing on each
other by placing padding such as pillows, soft
bony prominences. blankets, or towels between them.
These bony prominences are called pressure points
because they bear the weight of the body in certain
• Provide good lighting to prevent the client from
bumping into furniture, walls, and equipment.
positions (FIGURE 24–1). Pressure from body weight
can reduce blood supply to the area, which results in
a pressure ulcer. Pressure points that are moist with
perspiration or body excretions are especially prone to include breaks in skin; poor circulation to an area;
developing a pressure ulcer, as well as bacterial infec- moisture (such as perspiration or urine); dry, flaky
tions that are very difficult to treat once they set in. skin; and irritation from urine and stool. Pressure
occurs when the skin over a bony prominence is
squeezed between hard surfaces (the bone itself and
Causes of Pressure Ulcers another surface, such as a chair seat or mattress). In
Pressure, friction, and shearing are common causes obese people, pressure ulcers can develop in areas
of skin breakdown and pressure ulcers. Other factors where friction is caused by skin-to-skin contact.
Heels Sacrum Elbows Shoulder Back of

blades head
Heel Malleolus Leg Knees Thigh Greater Hip Shoulder Ear Side of
trochanter head
Cheek
and ear
Toes Knees Thighs Genitalia Ribs Breasts Acromial

(men) (women) processes
Elbows
Anterior superior iliac spines
Back of
head
Shoulders
Toes Shoulders
D
Sacrum E
Hips
Ischial
Heels Ischial Sacrum tuberosities
tuberosities
Feet
FIGURE 24–1 Pressure points: common pressure ulcer sites. A, The supine position.
B, The lateral position. C, The prone position. D, Fowler’s position. E, The sitting
position.
Pressure ulcers can also occur in thin people when FIGURE 24–4). It takes into account the client’s sensory
two bony areas are in direct contact with each other function, skin moisture, activity level, nutrition, and
(such as knees or ankles rubbing together). This likelihood of friction and shear when the client is
squeezing or pressure interferes with the blood flow moved.
to the skin and underlying tissues, preventing oxygen Friction scrapes skin, and the resulting wound
and nutrients from reaching cells (see the Supporting creates a portal of entry for microbes. For the scraped
Mr. Hansen: How Pressure Can Result in Skin Blister- area to heal, a good blood supply to the area and
ing box) and causing the death of the skin and tissues prevention of infection are necessary. A poor blood
in the area (FIGURES 24–2 AND 24–3). In many settings supply or an infection can lead to a pressure ulcer.
in both the U.S. and Canada, health care providers
use the Braden Scale, which is used to predict the Other High Risk Areas
likelihood of a client developing a pressure ulcer (see Skin fold areas—under breasts, between abdominal
folds, on legs and buttocks, and between toes—are
also at risk for infection (which can lead to the for-
mation of pressure sores). These areas, often missed
during a bed bath, are frequently warm and moist
because of perspiration and infrequent exposure to
air. In addition, some clients use body lotions that
tend to add moisture to the skin in these areas,
increasing the risk for infection. It is your respon-
sibility, as a support worker, to wash these body areas
well, ensure they are dried thoroughly, and report
any signs of redness or skin irritation to your super-
visor. A small piece of cloth or gauze inserted under
a large breast can help prevent moisture and friction—
and thus skin redness and breakdown—whenever a
bra is not worn. Some nurses apply barrier cream to
FIGURE 24–2 A pressure ulcer. (Source: HMP Communica-
tions. (2005, February). Proceedings from the November
the washed and dried skin fold areas. The client is
National V.A.C.(R). Ostomy Wound Management, 51(2A, then dressed. Consult with your supervisor (or the
Suppl.): 7S. Used with permission.) client) before trying this cream on a client.
A B
C D
FIGURE 24–3 Stages of pressure ulcers. A, Stage 1. B, Stage 2. C, Stage 3. D, Stage 4.

(Photos courtesy of Laurel Wiersema-Bryant, RN, MSN, Clinical Nurse Specialist, Barnes-
Jewish Hospital, St. Louis, MO.)
Protected when completed.
468
Client's name File No. Date of assessment

Braden Scale for
Predicting Pressure Sore Risk
Sensory Perception 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment Sensory Perception
Ability to respond meaningfully to Unresponsive (does not moan, Reponds only to painful stimuli. Responds to verbal commands, Responds to verbal commands. Score
pressure-related discomfort. flinch or grasp) to painful stimuli, Cannot communicate discomfort but cannot always communicate Has no sensory deficit which would
due to diminished level of except by moaning or restlessness discomfort or the need to be turned limit ability to feel or voice pain or
CHAPTER 24
consciousness or sedation OR OR discomfort.

OR has a sensory impairment which has some sensory impairment
limited ability to feel pain over limits the ability to feel pain or which limits ability to feel pain or
most of body. discomfort over ½ of body. discomfort in 1 or 2 extremities.
Moisture 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist Moisture
Degree to which skin is exposed Skin is kept moist almost constantly Skin is often, but not always moist. Skin is occasionally moist, Skin is usually dry, linen only
to moisture. by perspiration, urine, etc. Linen must be changed at least requiring an extra linen change requires changing at routine
Score
Dampness is detected every time once a shift. approximately once a day. intervals.
patient is moved or turned.
Activity 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Frequently Activity

Degree of physical activity. Confined to bed. Ability to walk severely limited or Walks occasionally during day, Walks outside room at least twice Score
non-existent. Cannot bear own but for very short distances, with or a day and inside room at least once
weight and/or must be assisted without assistance. Spends majority every two hours during waking
into chair or wheelchair. of each shift in bed or chair. hours.
Mobility 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation Mobility

Ability to change and control Does not make even slight changes Makes occasional slight changes Makes frequent, though slight, Makes major and frequent changes
body position. in body or extremity position without in body or extremity position but changes in body or extremity in position without assistance.
Score
assistance. unable to make frequent or position independently.
significant changes independently.
Skin Care and Prevention of Wounds
Nutrition 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent Nutrition

Usual food intake pattern. Never eats a complete meal. Rarely eats a complete meal and Eats over half of most meals. Eats most of every meal. Never
Rarely eats more than 1/3 of any generally eats only about ½ of any Eats a total of 4 servings of protein refuses a meal. Usually eats a total
Score
food offered. Eats 2 servings or less food offered. Protein intake includes (meat, dairy products) per day. of 4 or more servings of meat and
of protein (meat or dairy products) only 3 servings of meat or dairy Occasionally will refuse a meal, dairy products. Occasionally eats
per day. Takes fluids poorly. Does products per day. Occasionally will but will usually take a supplement between meals. Does not require
not take a liquid dietary supplement take a dietary supplement when offered supplementation.
OR OR OR
is NPO and/or maintained on clear receives less than optimum amount is on a tube feeding or TPN
liquids or IV's for more than 5 days. of liquid diet or tube feeding. regiment which probably meets
most of nutritional needs.
Friction and Shear 1. Problem 2. Potential Problem 3. No Apparent Problem Friction and Shear
Requires moderate to maximum Moves feebly or requires minimum Moves in bed and in chair inde-
assistance in moving. Complete assistance. During a move skin pendently and has sufficient muscle
Score
lifting without sliding against sheets probably sllides to some extent strength to lift up completely during
is impossible. Frequently slides against sheets, chair, restraints or move. Maintains good position in
down in bed or chair, requiring other devices. Maintains relatively bed or chair.
frequent repositioning with good position in chair or bed most
maximum assistance. S pasticity, of the time but occasionally slides
contractures or agitation leads to down.
almost constant friction.
© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved
Permission to use has been received. Total Score
Signature Designate Date
VAC 656e (2007-05) Ce formulaire est disponible en français.

FIGURE 24–4 The Braden Scale. © Copyright Barbara Braden and Nancy Bergstrom,
1988. All rights reserved.
prevent his heel from getting any worse. When he

Supporting Mr. Hansen: How shows it to you, you see that it is a doughnut-
Pressure Can Result in Skin shaped object made by wrapping a gauze strip
Blistering around a circular object. The blistered area seems
to be the same size and shape as the “doughnut
Mr. Hansen, a 75-year-old man, has been cared for dressing.”
by his wife (a retired nurse) at home since his stroke Uncertain about what to do about the blister,
5 years ago. He has limited use of his left side; you call your supervisor, who says that Mr. Hansen
however, being right-handed, he is able to assist his should discard the “doughnut dressing.” She
wife with his care in a number of ways. His wife explains that although it might prevent the heel
was admitted recently to the hospital for pneu- from getting a blister, that circular surface will
monia, so your agency has been hired to provide suffer from increased pressure and decreased blood
respite personal care and support to Mr. Hansen flow when Mr. Hansen is lying in bed with his heel
while she is recovering. resting flat on the bed, causing a pressure ulcer to
Today, while you are washing Mr. Hansen’s feet, develop on the skin under the doughnut dressing.
you notice a large doughnut-shaped blister on his You convey to Mr. Hansen what your supervisor
left heel. When you ask him about the blister, Mr. has said. After thinking about it, he asks you how
Hansen tells you that when a pressure ulcer he can prevent getting blisters (or pressure sores)
developed on his heel, his wife made something to on his heel in the future. What will you advise him?
Clients at Risk for Pressure Ulcers BOX 24–4 Stages of Pressure Ulcers
Clients at risk for pressure ulcers are the following:
Stage 1 The skin is redder than surrounding
• Those who must stay in bed or in a chair skin and does not return to its
• Those who require moderate to complete help in natural colour when relieved of
moving pressure (see FIGURE 24–3, A). This
• Those with loss of bowel or bladder control finding must be reported to the
• Those with poor nutrition nurse or supervisor promptly.
• Those with altered mental awareness
Stage 2 The skin cracks, blisters, or peels
• Those with problems sensing pain or pressure
(see FIGURE 24–3, B). There may be a
• Those with circulatory problems
shallow crater.
• Those who are older
• Those who are obese or very thin Stage 3 The skin is gone, and the underlying
tissues are exposed and damaged (see
FIGURE 24–3, C). There may be
Signs of Pressure Ulcers drainage from the area.
The first sign of a pressure ulcer is pale or greyed skin Stage 4 Muscle and bone are exposed and
or a warm, reddened area. Colour changes in skin damaged (see FIGURE 24–3, D).
may be hard to notice in dark-skinned clients, so if Drainage is likely.
the client is complaining of pain, burning, itching,
or tingling in the area (common signs and symptoms
of poor blood flow to the area), you should report describes pressure ulcer development. It is your
the complaint to your supervisor. However, some responsibility to check your client’s skin every time
clients may not feel anything unusual, so it is import- you provide personal care. You should also immedi-
ant that you observe your client and look for other ately notify your supervisor if you observe any signs
signs of poor blood flow to the area. BOX 24–4 of a pressure ulcer.
client’s care plan and adhere to the preventive meas-

Prevention and Treatment of ures described on it.
Pressure Ulcers Clients at risk for pressure ulcers are placed on a
Pressure ulcers develop over time. The longer pres- surface that reduces or relieves pressure—for example,
sure is exerted on skin, the greater the risk is that a foam, air, alternating air, gel, or water mattresses. The
pressure ulcer will develop. health care team decides on the best surface for the
Preventing pressure ulcers is much easier than client.
healing them. Good support care (which includes A physician orders specific pressure ulcer treat-
frequent position changes and ensuring a proper ment—wound care products, medications, treat-
diet with lots of fluid), cleanliness, and skin care ments, and special equipment—for each client. Your
are essential. The Think About Safety: Guidelines for supervisor and the care plan tell you what to do.
Preventing Pressure Ulcers box lists guidelines for pre- Special beds and other protective devices, described
venting skin breakdown and pressure ulcers. As below, are often ordered to prevent and treat pressure
always, it is important that you also follow your ulcers and other types of skin breakdown.
Think About Safety

Guidelines for Preventing Pressure Ulcers Change linens and clothing as needed. Give good
skin care.
• Follow the repositioning schedule in the care
plan. Some clients have to be repositioned at least • Check with your supervisor before using soap on
every 2 hours and some every 15 minutes. Each a client. Soap can dry and irritate the skin.
client’s care plan should have specific instructions • Apply a moisturizer on dry areas—hands,
in regard to that client. elbows, legs, ankles, and heels—but not on
the areas under the breasts, between skin
• Position the client as specified in the care plan.
Use pillows for support, as instructed by your folds, and between toes. Your supervisor will
supervisor. The 30-degree lateral position is rec- tell you what to use and where to apply it. As a
ommended (FIGURE 24–5). very wise nurse once stated, “Never grease a
crease!”
• Use proper lifting, positioning, and transferring
procedures to prevent friction and shearing (see • Give a back massage after repositioning the
Chapter 25). client. Do not massage bony areas or pressure
points. Never rub or massage reddened areas,
• To reduce the likelihood of shearing, do not raise
the head of the bed to more than 30 degrees. but massage the skin around the reddened
Always follow your client’s care plan. area. Be careful to never scratch or irritate
the skin.
• Provide good skin care. The skin must be clean
and dry after bathing and kept free of moisture • Keep linens clean, dry, and wrinkle-free.
from urine, stool, perspiration, and wound • Do not irritate the skin. Avoid scrubbing or
drainage. rubbing when bathing or drying the client.
• Minimize exposure of skin to moisture. Check • Use pillows and blankets to prevent skin-to-skin
incontinent clients (those with loss of bowel or contact and to reduce moisture and friction.
bladder control) frequently. Also check clients • Keep the client’s heels off the bed. Use pillows or
who perspire heavily and those with wound other devices as directed. Place the pillows or
drainage, paying particular attention when drying devices under the lower legs from mid-calf to
between the client’s toes and between skin folds. ankle.
Continued
Think About Safety—cont’d

• Use protective devices as instructed by your • Remember that areas that had pressure ulcers in
supervisor and the care plan. the past (but are now healed) are always at risk
• Remind clients sitting in chairs to shift their of redeveloping the ulcers. Pay particular atten-
positions every 15 minutes to decrease pressure tion to these areas, and follow the above
on bony points. Assist if requested. guidelines.
• Report any signs of skin breakdown or pressure
ulcers at once. Record your observations, accord-
ing to employer policy.
30-degree
lateral
position,
using pillows
FIGURE 24–6 Air flotation bed.
and foam
wedge.
Hip bone Another type of bed allows you to reposition

clients without having to move them. Depending on
30 degrees the bed, the client is turned to the prone or supine
Tailbone
position (see Chapter 25), or the angle of the bed is
Hip bone
Fleshy part tilted so the entire bed is angled side to side. Body
of buttocks alignment does not change, but pressure points
FIGURE 24–5 The 30-degree lateral position. Pillows are change as the position changes, and friction is
placed under the head, shoulder, and leg. This position
inclines (lifts up) the hip to avoid pressure on the hip. The
reduced. Some beds continually rotate from side to
client does not lie on the hip as in the side-lying position. side and are useful for clients with spinal cord
injuries.
If you are caring for a client in this type of special
Special Beds bed, it is your responsibility to inquire about the type
Some beds may have air flowing through the mattress of bedding that is required when making the bed.
(FIGURE 24–6), may be made out of a gel-like sub- Some mattresses require that incontinence or transfer
stance, or may be made out of a special foam material pads (see Chapter 34) not be placed under the client,
that conforms to the body. On these mattresses, the as this additional padding reduces the effectiveness
client seems to float, which allows body weight to be of the special mattress. For other mattresses, it is
evenly distributed and reduces pressure on bony recommended that the bottom sheet not be tucked
parts. under it.
fit the shape of the elbow (FIGURE 24–9); some have

Bed Cradle straps to secure them in place.
A bed cradle (Anderson frame) is a metal frame
placed on the bed and over the client. Top sheets are Heel Elevators
brought over the cradle to prevent pressure exerted Pillows or special cushions raise the heels off the bed
by these sheets on legs and feet (FIGURE 24–7). Top (FIGURE 24–10). Special braces and splints also keep
sheets either are folded back to expose the feet, if the pressure off the heels.
client is too warm, or tucked in at the bottom of the
mattress and mitred, if the client prefers it. They are Flotation Pads
also tucked under both sides of the mattress to protect Flotation pads or cushions (FIGURE 24–11) are like
the client from air drafts and chilling (see the Focus waterbeds, but they are made of a gel-like substance
on Home Care: Bed Cradles box.) with an outer case of heavy plastic. The pads can be
placed in chairs and wheelchairs, allowing the client
Elbow Protectors to sit comfortably without the risk of developing
Elbow protectors, made of foam rubber or sheepskin, pressure ulcers. The pad is placed in a pillowcase or
prevent friction between the bed and the elbow. They special cover to prevent the plastic from coming in
contact with the client’s skin.
FOCUS ON HOME CARE

Bed Cradles
A sturdy cardboard box can be used as a bed cradle
(FIGURE 24–8). Your supervisor would tell you how
to line the box to prevent pressure on the heels.
FIGURE 24–8 A cardboard box serves as a bed cradle. It

keeps top linens off the client’s feet.
FIGURE 24–7 A bed cradle is placed on top of the bed.

Linens are brought over the top of the cradle. FIGURE 24–9 Elbow protector.
Other Equipment
Trochanter rolls and footboards are also used to
prevent pressure ulcers (see Chapter 26).
LEG AND FOOT ULCERS

Some diseases may affect blood flow to and from the
legs and feet, which can cause pain, open wounds,
and edema (swelling caused by fluid collecting in
tissues). Infection and gangrene can result from the
open wound and poor circulation. Gangrene is a
FIGURE 24–10 Heel elevator. Image provided courtesy condition in which tissue dies and then decays. Gan-
Posey Company, Arcadia, CA.
grenous tissue may be black and have a foul smell
(see Chapter 37).
Clients with leg and foot ulcers need special skin
care, as directed by a physician. The nurse uses the
care-planning process to prevent skin breakdown on
legs and feet.
Circulatory Ulcers
Circulatory ulcers (vascular ulcers) are open
wounds on the lower legs and feet caused by decreased
blood flow through arteries or veins. People with
diseases affecting blood vessels are at risk for these
ulcers on legs and feet, which can be painful and hard
FIGURE 24–11 Flotation pad.
to heal. Depending on where they originate, they are
classified as venous ulcers or arterial ulcers.
Venous Ulcers
Egg Crate–Like Mattress Venous ulcers (stasis ulcers) are open wounds on
The egg crate–like mattress is a foam pad that looks the lower legs and feet caused by poor blood return
like an egg carton with peaks that distribute the through veins (FIGURE 24–12, A). Blood travelling
client’s weight more evenly. This mattress is placed from the feet to the heart must defy gravity. In people
on top of the regular mattress and encased in a special who are active, the use of leg muscles assists the valves
cover that protects it against moisture and soiling. in their leg veins to pump the blood upward.
Only a bottom sheet covers the mattress. Many Unfortunately, in some clients who are not active,
agencies do not use this type of mattress because it who are extremely obese, or who have circulatory
can aggravate pressure points and may be a fire problems, blood will pool in the leg veins, or the
hazard since it is made of flammable material. valves will not close well. As a result, blood will not
They are, however, inexpensive and commercially be pumped back to the heart normally, and blood
available, and some family physicians still recom- and fluid will collect in their legs and feet, resulting
mend them to their clients for home use. Although in edema in their legs and feet. If you compress your
clients should never smoke in bed, it is important to fingers into the swollen, edematous tissue and then
warn them of the particular dangers of doing so take away your fingers, you will notice that your
when using this or any other type of flammable mat- fingers have left a skin impression, which is called
tress pad. pitting edema.
Appearance
Edema in tissues will give them a swollen appear-
ance. If the edema is fairly recent, skin can also
appear shiny and stretched. Edema and venous ulcers
are painful and make walking difficult. Venous ulcers
A
may “weep” fluid. Healing is slow, and infection is a
great risk. If the edema lasts for a long period, skin
will change in appearance and texture. Small veins in
skin can rupture, allowing the hemoglobin in blood
(which gives blood its red colour) to enter tissues,
causing skin to darken and become dry, leathery, and
hard. Itching is common.
Causes
B Heels and the inner sides of ankles are common
sites for venous ulcers because these areas can be
easily injured. Scratching is also a common cause of
venous ulcers. Some ulcers occur spontaneously,
without any specific cause.
FIGURE 24–12 A, Venous ulcer. B, Arterial ulcer. Compare
their appearances and how they differ from each other. Prevention
(Source (for B): Black, J.M., & Hawks, J.H. (2005). Medical- It is important to prevent skin breakdown caused
surgical nursing: Clinical management for positive outcomes by poor circulation because skin breakdown leads to
(7th ed.). St. Louis, MO: W.B. Saunders.)
venous ulcers, which are hard to heal. The Think About
Safety: Guidelines for Preventing Venous Ulcers lists
guidelines that may be part of the client’s care plan.
Think About Safety

Guidelines for Preventing Venous Ulcers • Elevate the client’s legs according to the care
plan.
• Apply elastic stockings or elastic wraps according
to the care plan if it is within your scope of prac- • Have the client wear comfortable socks and
tice to do so (see Chapter 31). shoes.
• Remind the client not to sit with legs crossed. • Do not do anything that may irritate the skin.
Avoid scrubbing or rubbing when bathing or
• Do not use elastic garters to hold socks or hose
in place. Ensure that the tops of stockings are not drying the client.
so tight as to be restrictive. Provide good skin • Avoid massaging over pressure points. Never rub
care daily. Clean and dry between the toes. or massage reddened areas.
• Avoid injury to the client’s legs and feet. • Keep the heels off the bed. Use pillows or other
devices, as instructed by your supervisor. Place
• Keep linens clean, dry, and wrinkle-free.
the pillows or devices under the lower legs from
• Follow the care plan for walking and exercise, as
movement increases venous blood flow. mid-calf to ankle.
• Reposition the client at least every 2 hours. • Use protective devices, as directed by your super-
Follow the care plan. visor and the care plan.
• When positioning the client in bed, ensure that • Report signs of skin breakdown, venous ulcers,
there is adequate padding between the client’s or pressure ulcers at once.
body parts, through the use of pillows, soft blan-
kets, or towels.
The physician may order elastic stockings or elastic

bandages (see Chapter 31), which promote comfort Think About Safety
and circulation by providing support and pressure to Guidelines for Preventing Arterial Ulcers
the veins. Foot care by a professional with specialized
training in foot care, as well as medications or wound • Urge a client who smokes to quit smoking.
care products, may be ordered by the client’s phys- • Remind clients not to sit with legs crossed.
ician or nurse practitioner. • Avoid exposing the client to cold.
• Do not use elastic garters to hold socks and hose
Arterial Ulcers in place. Ensure that the tops of stockings are
Arterial ulcers are open wounds on the lower legs not so tight as to be restrictive.
and feet caused by poor arterial blood flow. • Make sure the client’s shoes fit well.
• Keep feet clean and dry.
Appearance • Keep pressure off heels and other bony points.
The affected leg and foot may feel cold and look • Avoid pressure under the knees.
grey or blue or shiny (FIGURE 24–12, B). The ulcer is • Check the client’s legs and feet daily. Report
often painful during rest and is usually worse at changes in skin colour or breaks in the skin to
night. Arterial ulcers are found between toes, on the your supervisor.
tops of toes, and on the outer sides of ankles. Heels • Avoid massaging over pressure points. Never
are common sites for arterial ulcers in people on bed rub or massage reddened or newly discoloured
rest. Arterial ulcers can also occur in pressure sites areas.
from shoes that fit poorly. • Use protective devices, as directed by your
supervisor and the care plan.
Causes
These ulcers are caused by diseases or injuries that
decrease arterial blood flow to the legs and feet— blood supply increases, signs and symptoms of
such as high blood pressure, diabetes, and narrowing inflammation—redness, swelling, heat or warmth,
of arteries due to aging. Smoking is a significant risk and pain—may appear, and there may be some
factor for vascular disease, such as atherosclerosis, loss of function.
arteriosclerosis, venous ulcers, or arterial ulcers. • Proliferative phase (day 3 to day 21). Proliferate
means multiply rapidly. Tissue cells multiply to
Treatment and Prevention repair the wound.
The physician directs the client’s care by treating • Maturation phase (day 21 to 1 or 2 years). The
the disease that caused the ulcer and ordering medi- scar tissue gains strength and appears red and
cations, wound care, and a walking program. You raised but eventually becomes thin and paler than
should never provide foot care to a client with an surrounding skin.
arterial ulcer unless it is specified in the client’s
care plan to prevent further injury. See the Think
About Safety: Guidelines for Preventing Arterial Ulcers
Types of Wound Healing
box. The healing process occurs through primary inten-
tion, secondary intention, or tertiary intention. With
primary intention (also called first intention or primary
WOUND HEALING closure), the wound is closed with sutures (stitches),
The healing process has three phases: staples, clips, or adhesive strips to hold the wound
edges together.
• Inflammatory phase (3 days). Bleeding stops, Secondary intention (also called second intention) is
and a scab forms over the wound, which pre- used in contaminated and infected wounds. Wounds
vents microbes from entering the wound. Blood are cleaned and dead tissue removed. Wound edges
supply to the wound increases, and the blood are not brought together—the wound is left gaping.
brings nutrients and healing substances. Because Healing occurs naturally but takes longer, and a
larger scar is formed. These wounds have a high risk and weak pulse; rapid respirations; and cold, moist,
of infection. and pale or greyish skin. A client experiencing shock
Tertiary intention (also called third intention or is restless and may complain of thirst. Confusion and
delayed intention) involves leaving a wound open for loss of consciousness eventually occur.
a time before then closing it. Thus, tertiary intention Hemorrhage and shock are emergencies, so notify
combines secondary and primary intentions. Infec- your supervisor immediately, and assist as requested.
tion and poor circulation are common reasons for Remember to follow Standard Practices when in
choosing tertiary intention. contact with blood. Gloves should always be worn,
and gowns, masks, and eye protection are necessary
when blood splashes and splatters are likely.
Complications of Wounds
Many factors affect healing and could increase the Infection
risk for complications—for example, the client’s age, Wound contamination can occur at any time during
general health, nutritional status and lifestyle, and or after an injury or surgery. Trauma often results in
the type and location of the wound. Clients with contaminated wounds, and surgical wounds can be
diabetes are at increased risk for infection. The client contaminated during or after surgery. An infected
might be very old, might have a medical condition wound has drainage and is painful and tender to the
(such as circulatory disease or diabetes), or may have touch (BOX 24–5). A client with an infected wound
a lifestyle risk factor (such as smoking or poor diet) may have a fever.
that might slow down the healing process. Other
clients may be on certain medications (such as war- Dehiscence
farin or heparin) that will prolong bleeding and pos- Dehiscence is the rupture or sudden separation of
sibly delay healing. the wound layers along a surgical suture line (FIGURE
Wound healing is dependent on good blood circu- 24–13). Separation may occur just at the skin layer or
lation to the wound as well as good nutrition for the affect underlying tissues, as usually seen in abdom-
client, with a diet rich in fluids (needed for tissue inal wounds. Coughing, vomiting, and abdominal
hydration), protein, and vitamin C (needed for tissue distension place stress on the wound. The client
growth and repair). The wound must be protected often describes a sensation of the wound popping
from infection. Sometimes, the client’s doctor may open.
prescribe antibiotics to prevent the development of
an infection. Evisceration
Evisceration is the separation of the wound, which
Hemorrhage is accompanied by protrusion of abdominal organs
Hemorrhage is excessive loss of blood within a short
period. If bleeding is not stopped, death results.
Hemorrhage may be internal or external. Internal
hemorrhage, when bleeding occurs into tissues and
body cavities, cannot be seen. It leads to a hema-
toma, which is a collection of blood under skin and
tissues. The area appears swollen and has a reddish-
blue or grey colour. Shock, vomiting blood, cough-
ing up blood, and loss of consciousness are signs of
internal hemorrhage. External bleeding is visible as
bloody drainage or through dressings soaked with
blood. As with internal hemorrhage, shock can occur.
Shock is a result of there not being enough blood
FIGURE 24–13 Wound dehiscence. (Source: Morison, M.
supply to organs and tissues. Signs and symptoms of (1992). A colour guide to the nursing management of wounds.
shock include low or falling blood pressure; rapid London, U.K.: Wolfe Medical Publishers.)
BOX 24–5 Wound Observations

Wound Location
• Where is the wound located on the body? Is
there more than one wound? (Multiple wounds
may exist from surgery or trauma.)
Wound Appearance
FIGURE 24–14 Wound evisceration. (Source: Ignatavicius,

• Is the wound red and swollen?
D.D., & Workman, M.L. (2002). Medical-surgical nursing: • Is the area around the wound warm to the
Critical thinking for collaborative care (4th ed.). Philadelphia, touch?
PA: Saunders.) • Are sutures, staples, or clips intact or broken?
• Are wound edges closed or separated? Did the
wound break open?
(FIGURE 24–14). Causes are the same as those of
dehiscence. Drainage
Dehiscence and evisceration are surgical emergen- • Is there drainage?
cies. Tell your supervisor at once if you see them. A • What is the amount of drainage?
nurse will cover the wound with a large sterile dress- • Is the drainage:
ing saturated with sterile saline, and the client will • Clear?
need emergency medical care. • Bloody?
• Watery and blood-tinged?
• Thick and green, yellow, or brown?
Wound Appearance
Odour
During the healing process, physicians and nurses
routinely observe the wound and its drainage for • Does the wound or drainage have an odour?
healing and complications. As a support worker, Surrounding Skin and Tissues
you also need to make certain observations when
• Is surrounding skin intact?
assisting with wound care. You should report your
• What is the colour of the surrounding skin?
observations to your supervisor, and record them,
• Are the surrounding tissues swollen?
according to employer policy. BOX 24–5 lists ques-
tions to consider when observing wounds.
Wounds Under Casts and Dressings

If you work in an acute-care setting, you may be Wound Drainage
responsible for caring for a client who has a wound During injury and during the inflammatory phase
that you cannot see, such as one inside a cast or of wound healing, fluid and cells escape from
under a large, bulky dressing. It is your responsibility tissues. The amount of drainage may be small or
to observe the wound area and to report your obser- large, depending on wound size and location and
vations. For example, if you discover that the client the presence of bleeding or infection. Although
has blood seeping through a freshly applied cast or the nurse is responsible for changing dressings, you
dressing, you must report the discovery to the nurse. need to observe and report to the nurse any type of
You may be instructed to mark the outline of blood wound drainage. You may also be shown how to
seepage through the cast or dressing and report any measure the amount of drainage and to document
further drainage. In this case, the client will also be the amount of drainage, depending on your
monitored for signs of blood loss, such as low blood employing agency and your scope of practice in your
pressure and a high pulse rate. province.
A B
FIGURE 24–16 A Penrose drain. The safety pin prevents the

drain from slipping into the wound. (Source: Potter, P.A., &
Perry, A.G. (2009). Fundamentals of nursing (rev. 7th ed.,
p. 1297). St. Louis, MO: Mosby.)
C D
FIGURE 24–15 Wound drainage. A, Serous drainage.

B, Sanguineous drainage. C, Serosanguineous drainage.
D, Purulent drainage. (Source: Potter, P.A., & Perry, A.G.
(2009). Fundamentals of nursing (rev. 7th ed., p. 1287).
St. Louis, MO: Mosby.)
Major types of wound drainage are as follows:
• Serous drainage—clear, watery fluid (FIGURE

24–15, A). The fluid in a blister is serous (from the
FIGURE 24–17 Hemovac. Drains are sutured to the wound
Latin word serum, meaning clear, thin, fluid and connected to the reservoir. (Source: Potter, P.A., &
portion of blood). Serum does not contain blood Perry, A.G. (2009). Fundamentals of nursing (rev. 7th ed.,
cells or platelets. p. 1329). St. Louis, MO: Mosby.)
• Sanguineous drainage—bloody drainage (FIGURE

24–15, B). The amount and colour of sanguineous
(from the Latin word sanguis, which means blood) drains onto a dressing (FIGURE 24–16). Because it is
drainage are important. Hemorrhage is suspected an open drain, it can act as a portal of entry for
when large amounts are present. Bright red drain- microbes.
age means fresh bleeding, whereas older bleeding Closed drainage systems prevent microbes from
is darker. entering the wound. A drain is placed in the wound
• Serosanguineous drainage—thin, watery drain- and attached to suction—for example, the Hemovac
age (sero) that is blood-tinged (sanguineous) (FIGURE 24–17) and Jackson-Pratt (FIGURE 24–18)
(FIGURE 24–15, C). systems. Depending on the wound type, size, and
• Purulent drainage—thick drainage that is green, location, other systems may be used.
yellow, or brown and may have a foul odour A nurse measures drainage in two ways:
(FIGURE 24–15, D).
• Noting the number and size of dressings with
Drainage must leave the wound for healing to occur. drainage—the amount and kind of drainage are
If drainage is trapped inside the wound, underlying described. Are dressings saturated? Is the drainage
tissues swell. The wound may heal at the skin level, on just part of the dressing? If so, which part?
but underlying tissues do not close, and infection Is the drainage occurring through some or all
and other complications can occur. When large layers?
amounts of drainage are expected, the physician will • Measuring the amount of drainage in the col-
insert a drain. A Penrose drain is a rubber tube that lecting receptacle—if closed drainage is used.
range of sterile dressing types and indications for

the use of each, and because it is beyond your scope
of practice to decide on the type of dressing, this
chapter focuses on the support worker’s respon-
sibilities in regard to a client’s dressing.
Although you are not responsible for sterile dress-
ing changes or for skin assessment (these tasks are the
responsibility of the nurse), you should function as
the “eyes and ears” of the client, reporting important
details about the dressings to the nurse (BOX 24–6).
Types of Dressings
Dressings are described by the material used and
application method. Many products are available for
dressing wounds. Dressings may be dry, moist, or
hydrocolloid (a substance that forms a gel in the
FIGURE 24–18 Jackson-Pratt drainage system. (Source: presence of water). The following are common
Potter, P.A., & Perry, A.G. (2009). Fundamentals of nursing dressings:
(rev. 7th ed., p. 1298). St. Louis, MO: Mosby.)
• Gauze—comes in squares, rectangles, pads, and
rolls (FIGURE 24–19). Gauze dressings absorb
DRESSINGS moisture.
Wound dressings have many functions: • Non-adherent gauze—a gauze dressing with
a nonstick surface. It does not stick to the
• They protect wounds from injury and microbes. wound and is removed easily without injuring the
• They absorb drainage. tissue.
• They remove dead tissue. • Vapour-permeable transparent adhesive film—
• They promote comfort. air can reach the wound but fluid and microbes
• They cover unsightly (ugly) wounds. cannot. The wound is kept moist. Drainage is not
• They provide a moist environment for wound absorbed. The transparent film allows wound
healing. observation.
• When bleeding is a problem, pressure dressings
help control bleeding.
Sterile Dressings
The type and size of dressing used depend on many
factors—(1) the type of wound, (2) its size and loca-
tion, (3) the amount of drainage, (4) the presence or
absence of infection, (5) the dressing’s function, and
(6) the frequency of dressing changes. The physician
and nurse choose the best type of dressing for each
wound. In many agencies, wound care is assessed by
a nurse who specializes in skin care of wounds and
around ostomies (see Chapters 32 and 33). You may
FIGURE 24–19 Different types of gauze dressings. (Source:
be asked to assist in the application of a sterile dress- DeWit, S.C. (2000). Fundamental concepts and skills for
ing (see Chapter 23). Because there is such a wide nursing (3rd ed.). St. Louis, MO: Saunders.)
BOX 24–6 The Support Worker’s Responsibilities to Clients With Wounds

Specific Areas Your Responsibilities
1. Overall • Follow the client’s care plan.
• Document all wound care or observations that you have
made.
• Participate in the interprofessional efforts by all team
members (Chapter 6) for wound care.
• Use proper hand hygiene and follow the rules of asepsis at
all times.
• Report and document any observations you have made
about your client in any of the areas noted below.
2. Prevention of Pressure Sores • Remove any restrictive clothing such as socks that are too
It is important that you observe tight, which can prevent blood circulation, leading to skin
your client’s skin, especially over the breakdown.
bony prominences, and report any • Ensure the client is repositioned at least every 2 hours (or
reddened areas. Remember that irri- more frequently if specified by the client’s care plan!).
tated areas can quickly become pres-
sure sores! • Inspect bony prominences that have been compressed by
any type of surface.
• Ensure that the client is correctly using the gel pad seat
cushion (used to reduce pressure on areas prone to pressure
ulcers).
• Keep bony prominences and skin folds clean and dry.
Wash skin after each soiling, and then rinse and pat dry.
• Pad between body parts to reduce likelihood of creating
pressure sores or skin irritation.
• Avoid oily soaps that trap bacteria, or drying, antiperspir-
ant soaps that can cause the skin to dry and crack. If pos-
sible, use peri-wash (a gentle pH-balanced soap), which
does not leave a residue on the client’s skin.
• Massage only around reddened areas, never directly on the
area, so as not to remove more skin cells.
• Never perform nail care if the client has diabetes or if the
client’s care plan states to avoid it. Nail care for some
clients should be done only by a professional with special-
ized training in foot care. Always report reddened areas or
ingrown toenails so that these can be treated as soon as
possible.
• Report and record your findings, according to your agency’s
policies.
Continued
BOX 24–6 The Support Worker’s Responsibilities to Clients With Wounds—cont’d
3. Pain and Comfort • Observe to find out if the client is in pain (look for grim-
A client in pain will probably not eat acing, holding a body part for a long period, or tensing
or participate in care. Pain may up during repositioning). If you find the client to be in
affect your client’s breathing and pain, determine where, the amount, the intensity, aggra-
moving, turning, repositioning, and vating factors, and the cause so that you can report and
walking. In addition, pain is exhaust- record this information appropriately.
ing and can make the client depressed • Handle the client gently.
or irritable. It is important that the
client be made as comfortable as • Report the client’s pain and details to the appropriate
nurse, who can give the client pain medication if it is
possible.
ordered and appropriate.
• Allow pain medications to take effect before giving care
(at least 1 hour).
• Assist the client into a comfortable position, and frequently
turn the client (according to the care plan) to avoid placing
pressure on compromised areas.
• If specified in the client’s care plan, massage around the
client’s bony prominences. Assist the client into a proper
body alignment, and position the client with pillows.
• Ensure that the client who is in bed is lying on a wrinkle-
free foundation.
4. Movement and Ambulation • Encourage the client to move in bed, take deep breaths,
Movement is important for every- and turn independently as much as possible.
one because it encourages deeper • Following the client’s care plan, assist the client into a chair
respirations and better blood circu- (or wheelchair) or to ambulate as often as stated. If the
lation, reduces the risk of pressure person is unable to ambulate, turn the client frequently,
ulcers developing, increases the body’s as indicated in the care plan.
metabolism, promotes peristalsis,
and improves digestion. Clients with • Schedule activities around the time the client receives pain
medication (at least 1 hour after) so that the client is as
painful wounds are often reluctant
comfortable as possible before attempting to ambulate.
to move or to ambulate, and those
with wounds that are foul smelling • Have another worker on hand to help, in case the client
may be self-conscious about leaving feels light-headed or faint.
their rooms, even if they can. • Encourage the client to rise slowly and to take a few deep
breaths before standing up to help eliminate any potential
feeling of light-headedness.
5. Dressings • Depending on where you live in Canada, dressing applica-
Depending on the type of dressing tion may be a delegated task from a nurse.
that is ordered for your client, the • Observe if the client’s dressing is clean and free from
appearance, care, and maintenance bodily fluids (such as urine or feces). Report pertinent
of the dressing may vary. Regardless information.
of type, all dressings should be kept
clean. • If required, assist the nurse with the client’s dressing change.
If the wound is particularly unsightly, be careful to control
your facial expressions so as not to alarm the client.
Continued

6. Nutrition and Hydration • Take the client’s care plan, dietary needs, and preferences
The client’s wound cannot heal with into account, and prepare tasty treats that are high in
a diet that is poor in protein or protein, vitamin C, and iron.
vitamin C. In addition, the client • If the client has diabetes, ensure that caloric restrictions
must have adequate fluid to replace are not exceeded.
any lost in wound drainage. The
client who is anemic will not have • Offer liquids frequently throughout the day to ensure
the client is adequately hydrated. Observe and report if
enough hemoglobin to bind with
the client’s urine output is low or dark in colour (see
oxygen, so the client must also eat
Chapter 32).
an iron-rich diet.
7. Oxygenation • Help the client to maintain positions that will maximize
Oxygen is a requirement for healing. lung expansion.
On a cellular level, oxygen must • Gently remind the client to take several deep breaths at
bind itself to hemoglobin (part of a least every hour.
red blood cell) and be transported
throughout the body.
8. Odour • Keep drainage containers out of the client’s sight.
Some wounds, especially those with • Open windows, whenever possible, to allow fresh air to
necrotic tissue (dead tissue), may enter the client’s room.
be very foul smelling, which can
embarrass the client and ruin the • Ensure that dressing materials are removed promptly and
placed in a plastic bag that is tied to contain the odour
appetite.
(see Chapter 23).
• Discreetly use room air fresheners to mask any odour.
• If possible, move the client into another room for meals.
9. Temperature • Take the client’s temperature, according to the care plan
Fever is the body’s way of fighting (see Chapter 15), and if there is a fever, report it. Often,
infection by increasing white blood fever is a sign of infection.
cells and blood flow to the area. Not • Report any abnormal findings at once. It is common for
all clients who have an infection older adults to have a normally low body temperature, so
will have a fever when you take the they may not seem to have a fever even if there is an infec-
temperature. Some clients (such as tion. Observe for other signs that indicate an infection
older adults or clients with immune (such as redness or swelling around the wound, tenderness,
challenges) may not have a fever in and warmth to the touch).
the presence of an infection.
10. Skin Care • Keep the client’s skin clean and dry. Avoid the use of
Clean, dry skin is less likely to powders, which may dry out the skin too much and may
harbour pathogens than moist, irritate the client’s airway.
soiled skin. Pathogens can cause skin • After washing the client’s skin, rinse it thoroughly and pat
infections, which, in turn, can lead it dry. Do not towel-dry roughly, as this action can actually
to skin ulceration and breakdown. tear the skin of some frail clients.
• Report and record any observations of edema, bruising,
swelling, or any other abnormal feature.
Continued

11. Maintaining Skin Integrity • Transfer or position the client gently. Use equipment
Intact skin is the body’s first line of properly. Use friction-reducing equipment, such as sliding
defence against pathogens. It is boards (see Chapter 25).
important that skin is kept intact, as • Never apply straps or boards directly on the skin, as this
it is easier to prevent a skin infection contact can increase the client’s risk of getting scratched
than it is to cure one. or bruised.
• Ensure that the client’s skin remains clean and dry at all
times. Follow all of the above steps to ensure the client’s
skin is not damaged at any time.
• Avoid tight, restrictive clothing.
12. Complications and Concerns • Be aware of the following:
Delayed healing is a risk for clients • These conditions are risk factors for infection.
who are older or obese or who have
poor nutrition. Poor circulation and • Survivors of abuse often hide the true source of their
injuries.
diabetes also affect healing.
Survivors of violence have many • The wound may affect the client’s sexual performance
other concerns. Fear of future attacks, or the client’s sense of being sexually attractive.
concerns about the attacker being • Eye injuries can affect vision.
found and convicted, and fear for
family members are common.
• Many clients with serious and disfiguring wounds have
an increased need for love and acceptance.
The wound may be disfiguring.
Whatever the wound’s location or • The client may have fears about scarring, disfigurement,
size, the client’s body image and self- delayed healing, and infection or may have fears about
esteem are often affected. the wound “popping open.”
Amputation of a finger, hand, • Be empathetic to the client’s feelings. The client may be
arm, toes, foot, or leg can affect sad and tearful or angry and hostile. Adjustments may be
the client’s function, daily activities, hard and rehabilitation necessary. Be gentle and kind, give
and job. compassionate care, and practise good communication.
The wound may be large or small. • Work in cooperation with other health care team
It may be visible to others—on the members—social workers, psychiatrists, therapists, and
face, arms, or legs—or hidden by spiritual advisors—who may be involved in the client’s
clothing. If the client had surgery, care.
anaesthesia and pain medication can
affect eating and elimination.
Some dressings contain special agents to promote nurse will direct you in regard to the particulars of
wound healing. If it is considered within your scope dressing change and care for each client.
of practice, and you are to assist with a dressing
change, your supervisor will explain the use of the
dressing to you. Dressing application methods involve Securing Dressings
a number of dressing types, depending on the client’s Dressings must be secure over wounds to avoid
particular type of wound. Your supervisor or the microbes entering the wound and drainage escaping
FIGURE 24–20 Tape is applied at the top, middle, and

bottom of the dressing. Note that the tape extends several
centimetres beyond both sides of the dressing.
(see the Focus on Children: Dressings box on this page

and Focus on Older Adults: Dressings box on p. 485).
Tape FIGURE 24–21 This type of dressing (shown here is

Adhesive, paper, plastic, and elastic tapes are common. Nexcare™ Tegaderm™ Transparent Waterproof Dressing) is
Adhesive tape sticks well to the skin, but removing clear and allows the wound to be observed while protecting
it. For wounds that may drain, there are bandages with a
the remaining adhesive can be difficult, and the small gauze square surrounded by the adhesive. These ban-
adhesive can irritate the skin. Some skin may come dages promote healing by allowing vapour and oxygen to
off with the tape, causing an abrasion. For clients penetrate the clear membrane. (Photo source: Copyright
who are allergic to adhesive tape, paper and plastic ©3M IPC 2016. All rights reserved. This material is repro-
duced by courtesy of 3M. No further reproduction is permit-
tapes are used since they do not usually cause allergic ted without 3M’s prior written consent.)
reactions. Elastic tape allows easier movement of the
body part.
Tape is applied to secure the top, middle, and FOCUS ON CHILDREN
bottom of the dressing (FIGURE 24–20). The tape Dressings
extends several centimetres beyond each side of the
dressing. The tape must not encircle the entire body Children are often afraid of dressing changes. Tape
part. If swelling were to occur, circulation to the removal is often painful for them, and the wound’s
part would be impaired. appearance can be frightening. It is important to
If the client can tolerate it, a picture-frame ensure that the child is calm and cooperative, or
dressing—where the tape is applied to all four the sterile field could become contaminated. A
edges—can be used. This method of wound dressing parent or caregiver should hold the child so that
is less likely to wrinkle or fall off. Many simple ban- the wound can be reached with ease. Holding or
dages already have adhesive tapes on all four edges playing with a favourite toy is often comforting to
or are transparent and allow for vapour and oxygen the child. To help decrease the child’s fear and
exchange through it (FIGURE 24–21). apprehension about dressings, you can suggest
that the child apply a dressing to a doll (and
remove it).
Applying Dressings
Your supervisor may ask you to assist with dressing
changes. Some employers allow support workers to
HEAT AND COLD APPLICATIONS
apply simple, dry, nonsterile dressings to simple Physicians and nurses often order heat and cold
wounds. BOX 24–7 lists guidelines for applying applications for wound care (see Chapter 44) to
nonsterile dressings (see the Focus on Home Care: promote healing and comfort and to reduce tissue
Changing Dressings box). swelling.
FOCUS ON OLDER ADULTS FOCUS ON HOME CARE

Dressings Changing Dressings
As we age, skin becomes thinner and more fragile, Your supervisor may ask you to telephone after
so skin tears are more common in older adults. removing the client’s old dressing. During this
Extreme care is, therefore, necessary when remov- telephone call, you should report your observa-
ing tape. One method that many nurses suggest tions, and your supervisor will give you instruc-
using is to “peel” the tape off by folding the edge tions on how to proceed further. Follow your
of the tape over and dragging it back. This tech- employer policy for disposing of dressings. Usually,
nique avoids lifting the skin, which can be uncom- employers require you to do the following:
fortable to the client and can injure the client’s • Place the used dressing in a plastic bag
skin. • Fasten the bag securely
• Dispose of the bag in the household garbage
BOX 24–7 Guidelines for Applying Nonsterile Dressings

• Make sure your province or territory allows you • Remove dressings in a way that prevents the
to perform the procedure. client from seeing the soiled side. The drainage
• Make sure the procedure is in your job and its odour may upset the client.
description. • Do not force the client to look at the wound, as
• Apply dressings only under a nurse’s direction the appearance of the wound can affect body
and supervision. image and self-esteem. The nurse will address the
• Review the procedure with the nurse. client’s concerns about the wound.
• Allow time for pain medications to take effect, • Remove the tape by pulling it toward the
as the client may experience discomfort during wound. You can ensure that the tape does not
the dressing change. The nurse will give the stick to the skin by, again, folding it back on
medication and tell you how long to wait. itself.
• Provide for the client’s fluid and elimination • Remove the dressing gently. If the dressing sticks
needs before starting the procedure. to the wound and surrounding skin, ask your
• Collect needed equipment and supplies before supervisor if the wound can be dampened (for
you begin. example, by applying sterile normal saline) to
• Be aware of your nonverbal communication. loosen the dressing from the wound.
Wound odours, appearance, and drainage may • Observe the wound, and report and record your
be unpleasant, but take care not to communicate observations, according to employer policy (see
your thoughts and reactions to the client. BOX 24–5 on p. 477).
• Follow Standard Practices. Wear personal pro-
tective equipment, as necessary. Never touch a
wound with ungloved hands.
Applying a Dry Nonsterile Dressing

Advocate on behalf of the client’s quality of life by promoting:
Dignity • Independence • Preferences • Privacy • Safety (see BOX 1–4, on p. 17)
PRE-PROCEDURE
1 Review the procedure with your supervisor. □ Dressing, as directed by the care plan
Being familiar with the procedure before begin- □ Dressing tray, as directed by the care plan
ning will reduce your anxiety and, in turn, the □ Clean, small gauze squares to wipe wound
client’s. area, as directed by the care plan
2 Identify the client, according to employer policy. □ Normal saline to clean the wound, as
This eliminates the possibility of mistaking one directed by the care plan
client for another. □ Adhesive remover
3 Explain the procedure to the client. □ Scissors
4 Allow time for pain medication to take effect □ Leak-proof plastic bag
(injectable medication may begin to work □ Bath blanket or clean sheet
within minutes, but oral pain medication may By collecting all the necessary equipment before-
take at least 1 hour). hand, you will not have to needlessly leave your
This will make the procedure more comfortable client’s side and can eliminate wasting time and
for the client. energy in obtaining the forgotten equipment. You
5 Provide for the client’s fluid and elimination will also avoid tiring the client needlessly.
needs. 8 Provide for privacy.
This will make the client more comfortable during 9 Arrange items on your work area.
the procedure. 10 Raise the bed to a comfortable working height.
6 Practise proper hand hygiene. Follow the care plan for bed rail use.*
7 Collect the following supplies: Raising the bed will reduce your risk for back
□ Gloves strain. Lowering the head of the bed will make it
□ Personal protective equipment, as needed easier to slide the client up to a better position.
□ Tape
PROCEDURE
11 Lower the bed rail near you if it is up. 16 Wear a gown and mask if necessary as directed
12 Help the client to a comfortable position. by the care plan.
13 Cover the client with a bath blanket or clean These measures decrease the risk for pathogen
sheet. Fan-fold the client’s top linen to the foot spread.
of the bed. 17 Put on gloves.
A fan-folded sheet is easier for the client to grasp 18 Remove tape by holding the skin down and
when it is time to cover up. gently pulling the tape toward the wound.
14 Expose the affected body part, leaving the rest Pulling the tape toward the wound is more com-
of the client as covered as possible. fortable for the client than pulling away from it.
This respects the client’s need for privacy and pre- It can also reduce the chance of reopening the
vents the client from being needlessly chilled. wound if it has not yet healed.
15 Make a cuff on the plastic bag. Place it within 19 Remove adhesive from the skin. Wet a 10 ×
reach and in a place that avoids crossing over 10 cm (4 × 4 in.) gauze dressing with the adhes-
the wound with soiled wipes. ive remover. Clean away from the wound.
Continued
Applying a Dry Nonsterile Dressing—cont’d

Adhesive left behind irritates the skin, so it should five or six onto the dressing tray or on the clean
always be removed. Cleaning away from the wrapper, staying as close to the centre of the
wound decreases the chance of introducing wrapper and the tray as possible.
pathogens or adhesive into the wound. The small gauze squares will be used to cleanse
20 Remove the gauze dressing. Start with the top the wound. Old drainage and dried blood left
dressing. Keep the soiled side of the dressing out behind on a wound can be a source of infection
of the client’s sight. and should be removed.
Keeping the soiled dressing out of sight reduces The outer 2.5 cm of the wrapper is regarded as
the client’s anxiety. contaminated.
21 Place the dressing in the leak-proof bag. It must 28 Cut the length of tape needed.
not touch the outside of the bag. 29 Put on clean gloves.
The outside of the bag must remain clean and 30 Using either the forceps supplied in the dressing
uncontaminated to reduce the risk for pathogen tray or your clean, gloved hand, pick up a small
spread. gauze square. Dip it into the normal saline
22 Remove the dressing directly over the wound solution.
very gently. 31 Wipe the wound in one long stroke down the
The old dressing may stick to the wound. By being middle of the wound from top to bottom.
rough, you can reopen a wound that hasn’t yet Discard the gauze square into the leak-proof
healed. bag. If you are using a cleaning cloth, use a fresh
23 Observe the wound and drainage (see BOX 24–5, corner for each stroke you use. Do not touch
on p. 477). Avoid showing the drainage to the the wound again with a soiled gauze square or
client. cleaning cloth.
Seeing the drainage may be upsetting to the The wound is wiped in long strokes, and the gauze
client. wipe is discarded after each wipe to prevent
24 Remove gloves. Put them in the bag. Practise pathogen spread.
proper hand hygiene. (If used, raise the bed rail 32 Wipe down the middle of the wound again and
before leaving the bedside. Lower it when you then on either side of the wound.
return.) Wiping is always done from the centre of the
25 Open the dressing tray. Unfold the clean or wound to the outside to prevent contaminating
sterile wrapper and ensure it stay opens. the wound.
The new dressing tray is opened after the soiled 33 Apply dressing, as directed by the care plan.
dressing is removed to reduce the risk of contam- 34 Secure the dressing in place using tape.
inating it. Tape prevents the dressing from falling off.
26 Pour the normal saline into the dressing tray, 35 Remove your gloves. Put them in the bag. Prac-
being careful not to splash it on the wrapper. tise proper hand hygiene.
Splashing will contaminate the wrapper. These steps decrease the risk for pathogen spread.
27 Open the small gauze square package and, using
the forceps supplied in the dressing tray, place
Continued
Applying a Dry Nonsterile Dressing—cont’d
POST-PROCEDURE
36 Provide for safety and comfort. 42 Clean your work surface, according to employer
37 Cover the client and remove the bath blanket policy.
or clean sheet. This reduces the risk for pathogen contamination
38 Place the call bell within reach.* of anything placed on that surface after the dress-
This provides an easy, safe way for the client to ing change.
contact the staff if necessary. 43 Practise proper hand hygiene.
39 Return the bed to its lowest position. Follow
the care plan for bed rail use.* Report and Record your actions and observa-
40 Remove privacy measures. tions, according to employer policy.
41 Discard supplies into the leak-proof bag. Tie the This is done for legal reasons and to keep the rest of
bag closed. Dispose of the bag, according to the health care team informed.
employer policy.
*Steps marked with an asterisk may not apply in community settings.

CHAPTER REVIEW
KEY POINTS REVIEW QUESTIONS

• Skin is the body’s first line of defence, protecting Answers to these questions are at the bottom of
the body from invading pathogens. page 490.
• A wound is a break in skin or mucous membranes Circle T if the answer is true, and circle F if the
and becomes a portal of entry for microbes and answer is false.
pathogens.
• The support worker’s role in wound care depends 1. T F Good nutrition and hydration can help
on provincial or territorial laws, job description, prevent skin breakdown.
and the client’s condition. 2. T F White, greyish, or reddened skin is the first
• Types of wounds include (1) intentional, (2) sign of a pressure ulcer.
unintentional, (3) open, (4) closed, (5) clean, and 3. T F Pressure ulcers do not usually occur over a
(6) contaminated. Wounds can also be described bony area.
according to their depth, such as (1) partial- 4. T F Pressure ulcers can develop from failing to
thickness or (2) full-thickness. reposition the client often enough.
• Skin tears occur due to friction, shearing, pulling, 5. T F Shearing and friction can cause pressure
or direct pressure. They should always be reported ulcers.
to the supervisor.
• Pressure ulcers are caused by unrelieved pressure Circle the BEST answer.
over a bony prominence. All support workers 6. A child fell off her bike. She has a laceration on
should know who is at risk for pressure ulcers and her right leg. She has a(n):
should observe for them and report any found A. Closed wound
immediately to the supervisor. B. Infected wound
• Support workers should know ways to prevent C. Contaminated wound
pressure ulcers. D. Intentional wound
• Circulatory ulcers include (1) venous ulcers and
(2) arterial ulcers. Their causes, appearances, and 7. Mrs. Katz had rectal surgery. What type of
treatment differ from each other. wound does she have?
• Complications of wounds include (1) hemor- A. A clean wound
rhage, (2) infection, (3) dehiscence, and (4) B. A dirty wound
evisceration. C. A clean-contaminated wound
• Wound drainage types include (1) serous, (2) san- D. A contaminated wound
guineous, (3) serosanguineous, and (4) purulent. 8. The piercing of skin and underlying tissues is
• Support workers should be familiar with the called a(n):
responsibilities of caring for clients with wounds. A. Penetrating wound
B. Hematoma
C. Contusion
CRITICAL THINKING IN PRACTICE D. Abrasion
You are dressing an older resident with thin, fragile
skin. You notice a new skin tear on the person’s arm.
What do you do? How can you prevent skin tears?
489
9. Which of the following can cause skin tears? 14. A wound appears red and swollen. The area
A. Keeping your nails trimmed and filed around it is warm to the touch. These signs
smooth occur during:
B. Dressing clients in clothing with long sleeves A. The inflammatory phase of wound healing
and long pants B. The proliferative phase of wound healing
C. Hurrying when lifting and transferring C. Healing by primary intention
clients D. Healing by secondary intention
D. Padding wheelchair footrests 15. A wound is healing by primary intention. While
10. Which of the following causes pressure ulcers? assisting with a dressing change, you note that
A. Repositioning the client every 2 hours the wound is separating. This is called:
B. Scrubbing and rubbing the skin A. Dehiscence
C. Applying lotion to dry areas B. Tertiary intention
D. Keeping linens clean, dry, and wrinkle-free C. Evisceration
D. Hematoma
11. Which of the following are used to treat or
prevent pressure ulcers? 16. You see clear, watery drainage from a wound.
A. Hospital beds This drainage is called:
B. Waterbeds and flotation pads A. Purulent drainage
C. Plastic drawsheets and waterproof pads B. Serous drainage
D. Heel “doughnut dressings” C. Seropurulent drainage
D. Serosanguineous drainage
12. You can help prevent stasis ulcers by:
A. Using elastic garters to hold socks in place 17. Which of the following does a dressing do?
B. Keeping the client in bed as much as A. Protects the wound from injury
possible B. Reduces swelling
C. Encouraging the client to sit with legs C. Prevents healing too fast
crossed D. Prevents oxygen from entering the wound
D. Avoiding injury to the legs and feet when 18. You are securing a dressing with tape. Tape is
giving care applied:
13. Which of the following areas is a common site A. Around the entire body part
for arterial ulcers? B. To the top and bottom of the dressing
A. On the scalp C. To the top, middle, and bottom of the
B. On top of the nose dressing
C. On the outer side of the ankle D. As the client prefers
D. Behind the knee
11.B, 12.D, 13.C, 14.A, 15.A, 16.B, 17.A, 18.C
Answers: 1.T, 2.T, 3.F, 4.T, 5.T, 6.C, 7.C, 8.A, 9.C, 10.B,
Chapter opener image: Joe Belanger/Shutterstock.com

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CHAPTER

• List clients at risk for skin tears and pressure ulcers.

BOX 24–2 Types of Wounds

• Penetrating wound—an open wound in which

forearm around her elbow. She also had several

Heels Sacrum Elbows Shoulder Back of

Toes Knees Thighs Genitalia Ribs Breasts Acromial

FIGURE 24–3 Stages of pressure ulcers. A, Stage 1. B, Stage 2. C, Stage 3. D, Stage 4.

Client's name File No. Date of assessment

consciousness or sedation OR OR discomfort.

Activity 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Frequently Activity

Mobility 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation Mobility

Nutrition 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent Nutrition

VAC 656e (2007-05) Ce formulaire est disponible en français.

prevent his heel from getting any worse. When he

client’s care plan and adhere to the preventive meas-

Think About Safety

Think About Safety—cont’d

Hip bone Another type of bed allows you to reposition

fit the shape of the elbow (FIGURE 24–9); some have

FOCUS ON HOME CARE

FIGURE 24–8 A cardboard box serves as a bed cradle. It

FIGURE 24–7 A bed cradle is placed on top of the bed.

LEG AND FOOT ULCERS

Think About Safety

The physician may order elastic stockings or elastic

BOX 24–5 Wound Observations

FIGURE 24–14 Wound evisceration. (Source: Ignatavicius,

Wounds Under Casts and Dressings

FIGURE 24–16 A Penrose drain. The safety pin prevents the

FIGURE 24–15 Wound drainage. A, Serous drainage.

Major types of wound drainage are as follows:

• Serous drainage—clear, watery fluid (FIGURE

• Sanguineous drainage—bloody drainage (FIGURE

range of sterile dressing types and indications for

BOX 24–6 The Support Worker’s Responsibilities to Clients With Wounds

BOX 24–6 The Support Worker’s Responsibilities to Clients With Wounds—cont’d

BOX 24–6 The Support Worker’s Responsibilities to Clients With Wounds—cont’d

FIGURE 24–20 Tape is applied at the top, middle, and

(see the Focus on Children: Dressings box on this page

Tape FIGURE 24–21 This type of dressing (shown here is

FOCUS ON OLDER ADULTS FOCUS ON HOME CARE

BOX 24–7 Guidelines for Applying Nonsterile Dressings

Applying a Dry Nonsterile Dressing

Applying a Dry Nonsterile Dressing—cont’d

Applying a Dry Nonsterile Dressing—cont’d

*Steps marked with an asterisk may not apply in community settings.

KEY POINTS REVIEW QUESTIONS

Chapter opener image: Joe Belanger/Shutterstock.com

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